Spending money to fix potential fall hazards in Maori homes in New Zealand reaps dividends

The research team was led by Michael D Keall from the University of Otago in Wellington. The design of the study, known as Maori Home Injury Prevention Intervention (MHIPI) study and conducted in the Wellington and Taranaki regions of New Zealand, was described in detail in another article in 2020.

The latest paper by Dr Keall and colleagues on MHIPI study appeared in The Lancet Public Health journal on 9 August. It was part of a special collection published by various Lancet journals on that day to shed light on the health and wellbeing issues affecting indigenous people around the world.

The authors point out that making home modifications in Maori households could offer a way to ‘reduce some of the current large inequities in injuries for Maori’.

They explain the rate of claims for treatment following falls in New Zealand is relatively high. Interventions are delivered by physiotherapists and other healthcare professionals after claims have been approved by the country’s national, ‘no-fault’ personal injury insurer, the Accident Compensation Corporation (ACC)

‘The accessibility of this [ACC] scheme is reflected by the high prevalence of injury claims for medical treatment in New Zealand. In 2018, there were 0·43 medically treated injury claims per head of population, of which 39 per cent were fall injuries, although part-charges required for some medical treatments can act as a barrier to seeking treatment.’

Definition of a fall

The team used the following definition of a fall: ‘an unexpected event in which the participants come to rest on the ground, floor, or lower level’, involving loss of balance.

‘We used this recommendation to ensure injuries from the ACC claims data were related to a fall event. The home setting was defined to include indoor and outdoor areas of the property,’ the authors state.

They point out that, on average, Maori households in New Zealand tend to be relatively large (with a mean of 3·4 residents per dwelling compared with 2·7 for all ethnic groups). This means that attempts to improve safety in Maori homes can potentially have a big impact.

Although New Zealand is a relatively wealthy, high-income nation, deficiencies in its housing stock have been identified in areas such as thermal protection and safety, they point out.

‘Our study confirms that houses occupied by Maori can be made significantly safer by applying a package of safety modifications.’

The research focused on owner-occupiers as they are less likely to move than those in rental properties, and because the owner of the house had to give consent for the modifications to be made.

‘The intervention tested would be likely to produce even greater safety benefits if applied to rental housing in New Zealand, which is on average a less safe environment than owner-occupied housing as included in this study,’ the research team states.

Eligibility criteria

Only households stating that they intended to remain at the same address for three years were eligible. Those assigned randomly to the intervention group received modifications such as handrails for outside steps and internal stairs, grab rails for bathrooms, outside lighting, repairs to window catches, high-visibility and slip-resistant edging for outside steps.

Other modifications included fixing the lifted edges of carpets and mats, installing non-slip bathmats, and applying slip-resistant surfacing to outside areas such as decks. (Those assigned to the control group received the modifications three years later).

‘After adjustment for previous falls and geographical region, there was an estimated 31 per cent reduction in the rate of fall injuries at home per year exposed to the intervention compared with households in the control group.’

Low-cost intervention: big impact

The analysis suggests the home modification intervention is highly cost-effective for Maori homes as each fall injury was prevented at a relatively low cost (of around NZ$575, or approximately £300) [Michael D Keall et al.]

Low-cost home modifications and repairs can be an effective means to reduce injury disparities, the authors state.

'The high prevalence of modifiable safety issues in Maori homes merits considerable policy and community effort. Given the substantial health burden of falls and their preventability, it is surprising that more attention is not devoted to modifying the built environment as a means of preventing falls.'

They add: ‘Our study shows the potential for home modification to address inequities in injury rates for Maori, New Zealand's Indigenous population, who are more likely than non-Maori to live in rented accommodation and in older homes.

‘The 31 per cent reduction in home fall injury rates and 40 per cent reduction in injuries specific to the intervention were significant. The analysis suggests the home modification intervention is highly cost-effective for Maori homes as each fall injury was prevented at a relatively low cost (of around NZ$575, or approximately £300).'

Falls: some key facts from the paper

• fall injuries globally were responsible for 1·4 per cent of disability-adjusted life-years (DALYs) due to disease and injury in 2017
• in terms of age-standardised DALYs in 2017, falls as a cause of health loss were ranked as the 18th most common cause globally, higher than chronic kidney disease, Alzheimer's disease and other dementias, and asthma
• compared with other injury types, falls were ranked third, following road injury and self-harm
• high-income countries, which commonly have growing proportions of older people, are likely to face corresponding increases in fall injuries (which already place a considerable burden on hospitals and society)
• falls in New Zealand resulted in 567 deaths and accounted for 4·6 per cent of total DALYs in 2017, and were by far the most important cause of injury-related health loss
• an average of 544 unintentional deaths due to falls occurred annually from 2014-2016
• more than 24,000 hospital discharges were recorded annually for unintentional fall injuries from 2014–18 
• on average, 658,000 falls a year required some form of medical treatment, more than half of which occurred at home (if the setting was defined) from 2011–18

New Zealand has a 'constitutional obligation' to address the kind of inequities highlighted in this study, as initially expressed in an 1840 agreement between the colonising English and Maori, the authors note.

To see the full version of Home modifications to prevent home fall injuries in houses with Maori occupants (MHIPI): a randomised controlled trial, visit: https://doi.org/10.1016/S2468-2667(21)00135-3

The series published by The Lancet journals marked this year’s United Nations' International Day of the World's Indigenous Peoples, which took place on 9 August.  

Content in the collection normally sits behind a paywall but is free to access with registration until 16 August.